nurs 6051c transforming nursing and healthcare through technology module 1 agenda setting weeks 1 2
December 18, 2020
3 questions and 1 case study
December 18, 2020

Can you please write 2 soap notes Following the example below You can use some of the wording from the example ( All the bolded areas from the example need to be kept Fallow the exact exalple of the soap note provided only changing what is appropriate to the case ) 1) Leg Edema Possible DVT 44 y/o female 2) Lymphadenopathy of the neck on 63y/o male SOAP Sample S: Chief Complaint: “I have no energy.” HPI:25 y/o Caucasian male presents to the clinic today with complaint of lethargy and feeling progressively more tired and lethargic. He stopped taking his thyroid medication six months ago.The patient discontinued his thyroid medication because he didn’t feel like he needed it any longer. He reports general lethargy increasing in frequency to daily over the past six months. He describes a feeling of “fog” in his head, falling asleep at work, and lasting from the time he wakes up until he goes to bed.Patient also reports weight gain of 20 pounds over the past six months.Reports pain 0/10 on 0-10 scale.He reports nothing makes the feeling of being tired any better. He states he has been using caffeine and energy drinks to help him feel better without success.The lethargy occurs daily and has begun to interfere with his job and his social life. Medications: None Noted. Allergies:NKDA.No food, insect or environmental allergies noted. Personal/Social History:Denies using alcohol; denies tobacco use; denies illicit drug use; able to complete all ADL’s without difficulty; able to complete all IADL’s without difficulty; does not exercise and eats a lot of fast food. O: T 97.7, BP 140/82, HR 75, RR 18, SpO2 98%, BMI 34.9.Neuro: A&Ox4, Balance and gait intact.Respiratory: Symmetric chest wall, RR clear with no distress noted.Lung fields intact to palpation.No rales, rhonchi, wheezes or rubs.Cardiovascular: RR intact, S1 and S2 intact with no S3 or S4, no clicks, rubs or murmurs.Capillary refill <2 seconds.No edema noted to BLE. Thyroid: No thyromegaly or nodules. A:Patient presents to clinic with complaints of tiredness, lethargy and weight gain. ICD-10:E03.9 Acquired Hypothyroidism, R53.83 Fatigue, Z68.34 BMI, Adult 34.0-34.9 P:Labs Ordered:CBC with differential, CMP, TSH, FREE T3, FREE T4, LIPID PANEL TODAY. RTC for f/u in 1 week to discuss lab results. Levothyroxine will be restarted if thyroid levels are out of range at f/u, dosage to be determined at f/u.Educated patient on s/s of hypothyroidism, disorders.Educated patient on healthy lifestyle choices, diet, exercise and adequate sleep. Patient voiced understanding of teaching provided.
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